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==Background==
==Background==
*Substances that cause damage on contact with body surfaces
{{Skin anatomy background images}}
*Degree of injury determined by pH, concentration, volume, duration of contact
{{Caustics background}}
*Etiologies for shock include GI bleeding, perforation, volume depletion
**Intentional ingestion a/w higher grade injuries
*Esophageal injuries
**Mild injuries - normal function is restored
**Severe injuries - strictures
*Days 2-14 post-injury are a/w highest tissue friability / risk of perforation
*High-grade caustic burns a/w 1000x increase in esophageal SCC
===Alkalis===
*Hydroxide ion easily penetrates tissue causing immediate cellular destruction
**May cause deep penetration into surrounding tissues (e.g. abd/mediastinal necrosis)
*Examples
**Bleach, drain openers, oven cleaners, toilet cleaner, hair relaxers
**Household bleach rarely causes significant injury
===Acids===
*Hydrogen ion leads to cell death and eschar formation, which limits deeper involvement
**However, due to pylorospasm and pooling high-grade gastric injuries are common
***Mortality rate is higher compared to strong alkali ingestions
*Ingestion may be complicated by systemic absorption (met acidosis, hemolysis, ARF)
*Examples
**Auto batteries, drain openers, metal cleaners, swimming pool products, rust remover


==Diagnosis==
==Clinical Features==
*All pts w/ serious esophageal injuries have some initial sign or symptom
[[File:1215px-My hand with minor chemical burns.jpg|thumb|Hand with minor chemical burns exposure to commercial-grade dishwasher with concentrated chlorine.]]
**E.g. stridor, drooling, vomiting
[[File:Sodium hydroxide burn.png|thumb|Chemical burn caused by sodium hydroxide solution (lye) 44 hours after exposure.]]
[[File:Chemical burn CaCN2.png|thumb|Lower leg chemical burn caused by calcium cyanamide.]]
[[File:Silbernitrat-Verätzung Collage.jpg|thumb|Water-thinned silver nitrate chemical burn on hand. Left: 7 hours after injury. Right: 26 hours after injury.]]
[[File:Mustard gas burns.jpg|thumb|Caustic burn caused by exposure to [[mustard gas]] (World War I).]]
[[File:HF burned hands.jpg|thumb|Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.]]
*Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion <ref>Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.</ref>
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*Exam eyes and skin (splash and dribble injuries may easily be missed)
*GI tract injury
*GI tract injury
**Dysphagia, odynophagia, epigastric pain, vomiting
**[[Dysphagia]], odynophagia, [[epigastric pain]], [[vomiting]]
*Laryngotracheal injury
*Laryngotracheal injury
**Dysphonia, stridor, respiratory distress
**[[Dysphonia]], [[stridor]], [[respiratory distress]]
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes
**Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes


==Work-Up==
==Differential Diagnosis==
===Labs===
{{Caustic burn types}}
Only necessary in pts w/ significant injury
**CBC
**Chemistry
**VBG
***Anion gap acidosis due to lactate production (tissue injury) or from the acid itself
****May also have non-anion gap acidosis (e.g. HCl)
**Lactate
**LFTs
**Coags
**Type and screen
**Calcium level
***If HF acid exposure
**ECG
**Screens for coingestants in suicidal pts
**May show QT-prolongation if hypocalcemic 2/2 HF acid
===Imaging===
*Upright CXR
**Detect peritoneal and mediastinal air
*Left-side down CXR
**Indicated if unable to tolerate upright CXR
*CT
**Consider when perforated viscus is suspected or after intentional ingestion


==Treatment==
{{Burn DDX}}
#Prevent personal exposure to the caustic agent
 
#Airway
==Evaluation==
##Should be considered as a difficult airway
*Clinical diagnosis
##Blind nasotracheal intubation is contraindicated
 
##First-line is awake oral intubation w/ direct visualization
===Work-up===
##LMAs, combitubes, bougies are probably unsafe; should be used as last resort
Only necessary in patients with significant injury or volume of ingestion
##Surgical back-up is recommended
 
#Steroids
Consider:
##Some toxicologists recommend single dose of dexamethasone 10mg IV (06mg/kg in peds)
*CBC
#Decontaminate in usual manner
*Metabolic panel
#Activated charcoal
*[[Lactate]]
##Only consider when coingestants pose a risk for severe systemic toxicity
*Calcium level (if [[Hydrofluoric acid]] exposure)
#
*[[ECG]]
**May show QT-prolongation if hypocalcemic secondary to Hydrofluoric acid
*APAP/ASA levels if concerned about coingestion (suicidal patients)
 
==Management==
*First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
*Brush any dry chemicals off the patient
*Irrigate all wounds and areas of exposure with copious amounts of water
**Exception: dry lime, phenol, metals such as potassium and sodium, causes harmful exothermic reaction
 
===Acidic injuries (except [[Hydrofluoric acid]])===
*May also have [[non anion gap acidosis]] (e.g. HCl)
*Respond well to copious saline or water irrigation
 
===Alkali injuries===
*May appear superficial but often are deeper with ongoing burn
*Treat with copious irrigation and local wound debridement to remove residual compound


==Disposition==
==Disposition==
*Admit the following:
**Injuries that cross flexor or extensor surfaces
**Facial injuries
**Perineum injuries
**Partial-thickness injuries >10-15% of [[BSA]]
**All full-thickness burns


==See Also==
==See Also==
*[[Burns]]
*[[Caustic keratoconjunctivitis]]
*[[Caustic ingestion]]


==Source==
==References==
Tintinalli
<references/>


[[Category:Tox]]
[[Category:Dermatology]]
[[Category:Toxicology]]
[[Category:Trauma]]
[[Category:Symptoms]]

Revisión actual - 16:18 11 dic 2024

Background

Normal dermal anatomy.

Caustics

  • Substances that cause damage on contact with body surfaces
  • Degree of injury determined by pH, concentration, volume, duration of contact
  • Acidic agents cause coagulative necrosis
  • Alkaline agents cause liquefactive necrosis (considered more damaging to most tissues)
  • Corrosive agents have reducing, oxidising, denaturing or defatting potential

Alkalis

  • Accepts protons → free hydroxide ion, which easily penetrates tissue → cellular destruction
    • Liquefactive necrosis and protein disruption may allow for deep penetration into surrounding tissues
  • Examples
    • Sodium hydroxide (NaOH), potassium hydroxide (KOH)
      • Lye present in drain cleaners, hair relaxers, grease remover
    • Bleach (sodium hypochlorite) and Ammonia (NH3)
      • Cleaning products such as oven cleaners, swimming pool chlorinator
      • Household bleach ingestion (4-6% sodium hypochlorite) rarely causes significant esophageal injury[1][2]

Acids

  • Proton donor → free hydrogen ion → cell death via denatured protein → coagulation necrosis and eschar formation, which limits deeper involvement
    • However, due to pylorospasm and pooling of acid, high-grade gastric injuries are common
      • Mortality rate is higher compared to strong alkali ingestions
  • Can be systemically absorbed and → metabolic acidosis, hemolysis, AKI
  • Examples
    • Hydrochloric acid (HCl), hydrofluoric acid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
      • Found in: auto batteries, drain openers, toilet bowl, metal cleaners, swimming pool cleaners, rust remover, nail primer

Clinical Features

Hand with minor chemical burns exposure to commercial-grade dishwasher with concentrated chlorine.
Chemical burn caused by sodium hydroxide solution (lye) 44 hours after exposure.
Lower leg chemical burn caused by calcium cyanamide.
Water-thinned silver nitrate chemical burn on hand. Left: 7 hours after injury. Right: 26 hours after injury.
Caustic burn caused by exposure to mustard gas (World War I).
Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.
  • Signs and symptoms are inadequate to predict presence or severity of injury after caustic ingestion [3]
  • Exam eyes and skin (splash and dribble injuries may easily be missed)
  • GI tract injury
  • Laryngotracheal injury

Differential Diagnosis

Caustic Burns

Burns

Evaluation

  • Clinical diagnosis

Work-up

Only necessary in patients with significant injury or volume of ingestion

Consider:

  • CBC
  • Metabolic panel
  • Lactate
  • Calcium level (if Hydrofluoric acid exposure)
  • ECG
    • May show QT-prolongation if hypocalcemic secondary to Hydrofluoric acid
  • APAP/ASA levels if concerned about coingestion (suicidal patients)

Management

  • First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
  • Brush any dry chemicals off the patient
  • Irrigate all wounds and areas of exposure with copious amounts of water
    • Exception: dry lime, phenol, metals such as potassium and sodium, causes harmful exothermic reaction

Acidic injuries (except Hydrofluoric acid)

Alkali injuries

  • May appear superficial but often are deeper with ongoing burn
  • Treat with copious irrigation and local wound debridement to remove residual compound

Disposition

  • Admit the following:
    • Injuries that cross flexor or extensor surfaces
    • Facial injuries
    • Perineum injuries
    • Partial-thickness injuries >10-15% of BSA
    • All full-thickness burns

See Also

References

  1. ↑ Wasserman RL, Ginsburg CM. Caustic substance injuries. J Pediatr. 1985;107(2):169-174. doi:10.1016/s0022-3476(85)80119-0
  2. ↑ Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope. 1997;107(1):122-125. doi:10.1097/00005537-199701000-00023
  3. ↑ Gaudreault, P. et al. Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics. 1983;71(5):767-770.
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